Host Home Application Form

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Step 1 of 11 - About This Form

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Thank you for you interest in becoming a Host Home Provider/Alternative Care Provider for Laradon’s Adult Residential Services Department. Enclosed is a Laradon Host Home Provider/Alternative Care Provider Questionnaire and Employment/Contractor Inquiry Release/Authorization form. Please complete all forms and return to the address listed below so that we can begin your application process. You will only be considered for a possible Host Home Provider/Alternative Care Provider when all forms are returned completely filled out.

Name*

First Middle Last

Address*

Street Address City State / Province / Region ZIP / Postal Code Country

Home Phone

Work Phone

Cell Phone

Email*

Enter Email Confirm Email

How many other residents, aside from Individuals in IDD services, will be living at the residence?*

Resident 1

Full Name

Date of Birth

MM slash DD slash YYYY

Relationship to Potential Provider

Resident 2

Full Name

Date of Birth

MM slash DD slash YYYY

Relationship to Potential Provider

Resident 3

Full Name

Date of Birth

MM slash DD slash YYYY

Relationship to Potential Provider

Resident 4

Full Name

Date of Birth

MM slash DD slash YYYY

Relationship to Potential Provider

Do you live in a(n)

House

Apartment

Mobile Home

Do you own or rent?

Own

Rent

Number of Bedrooms

Please enter a number from 0 to 10.

Number of Bathrooms

Please enter a number from 0 to 10.

How long at current address?

Would you be willing to make adaptions for handicap devices?

Yes

Insurance Information

Who is your insurance carrier?

Who is your agent?

What coverage do you have?

Do you drive a vehicle?

Yes

Driver License Number

How many people does your vehicle safely transport?

Please enter a number from 2 to 12.

Have you had any accidents/tickets within the last 5 years?

Yes

Please explain

Insurance Information

Who is your insurance carrier?

Who is your agent?

What coverage do you have?

What is the last level of education completed

High School

High School Name

Location

Street Address City State / Province / Region ZIP / Postal Code Country

College/University (Undergraduate)

College/University Name

Area of Study

College/University (Graduate)

College/University Name

Area of Study

List professional, trade, business or civic activities and offices held.

Are you currently employed?

Yes

Number of Hours/Week

Please enter a number from 1 to 80.

Will you continue with employment if selected as a HHP/RCP?

Yes

Will you be able to meet your monthly bills without a monthly host home payment?

Yes

Start with your most recent job or experience. Include any job-related military service assignments and volunteer activities. You may exclude organizations, which indicate race, color, religion, gender, national origin, handicap, or other protected status.

Current/Most Recent Job

Start Date

Month

Day

Year

End Date

Month

Day

Year

Employer Name

Employer Address

Street Address City State / Province / Region ZIP / Postal Code Country

Employer Phone Number

Your Job Title

Duties Performed

Supervisor Name

Starting Pay

Ending Pay

Hourly Rate

Reason for Leaving

Previous Job

Start Date

Month

Day

Year

End Date

Month

Day

Year

Employer Name

Employer Address

Street Address City State / Province / Region ZIP / Postal Code Country

Employer Phone Number

Your Job Title

Duties Performed

Supervisor Name

Starting Pay

Ending Pay

Hourly Rate

Reason for Leaving

Previous Job

Start Date

Month

Day

Year

End Date

Month

Day

Year

Employer Name

Employer Address

Street Address City State / Province / Region ZIP / Postal Code Country

Employer Phone Number

Your Job Title

Duties Performed

Supervisor Name

Starting Pay

Ending Pay

Hourly Rate

Reason for Leaving

References: Give name, address, and telephone number of three references who are not related to you and are not your previous employer.

Reference 1

Full Name

Phone Number

Reference Address

Street Address City State / Province / Region ZIP / Postal Code Country

Reference 2

Full Name

Phone Number

Reference Address

Street Address City State / Province / Region ZIP / Postal Code Country

Reference 3

Full Name

Phone Number

Reference Address

Street Address City State / Province / Region ZIP / Postal Code Country

May Laradon contact all persons and employers listed on this questionnaire?

Yes

Have you ever been a Laradon employee before?

Yes

Start Date

Month

Day

Year

End Date

Month

Day

Year

Are you prevented from lawfully working in this country because of Visa or Immigration Status?

Yes

Do you or does anyone living in your home currently have any type of communicable disease?

Yes

Please explain

Have you or any member of your family ever been arrested for violations of any law other than minor traffic violations?

Yes

Please explain

Have you or any member of your family ever been convicted of any felony, child abuse, or an unlawful sexual offense?

Yes

Please explain

Why are you interested in providing Host Home Services?

What experience do you have working with people with developmental disabilities?

What qualities do you feel are needed by the Provider to make a Host Home a success?

List the skills that you possess that would make you a successful Host Home Provider

Are you interested in permanent or temporary placement of a participant in your home?

Temporary

Permanent

Are you interested in providing services to a particular person?

Yes

Please list the person's name and how you know this person

Leisure (At Home)

	Often	Sometimes	Rarely	Never
Television
Video Games
Table Games
Active Games
Excercise
Gardening
Plants
Household Chores
Taking Walks
Knitting/Needlework
Woodworking/Crafts
Collecting
Drawing/Painting
Listening to Music
Outdoor Sports
Books/Magazines
Photography
Keeping a Pet
Chatting With Friends
Cooking

Recreation

	Often	Sometimes	Rarely	Never
Hiking
Going Out to Eat
Movies
Sporting Events
Shopping
Museums/Exhibits
Church
Social Events
Musical Shows
Theatre
Concerts
Dancing/Parties
Special Interest Groups
Community Groups
Swimming
Camping
Live Shows
Senior Centers
Traveling
Fairs/Carnivals
Amusement Parks
Lectures/Speakers
Visiting Family/Friends
Walking Around the Mall
Classes
Fishing
Parks
Bingo

Host Home Application Form

Resident 1

Resident 2

Resident 3

Resident 4

Insurance Information

Insurance Information

High School

College/University (Undergraduate)

College/University (Graduate)

Current/Most Recent Job

Previous Job

Previous Job

Reference 1

Reference 2

Reference 3

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